Don't take the decision to have an elective caesarean section lightly warn clinical negligence experts

Posted: 17/04/2012

In International Caesarean Awareness Month, Penningtons' clinical negligence team warns that the decision to proceed with an elective caesarean section should not be taken lightly by either the treating clinicians or the mother. One in four women in the UK, many European countries, Asia and America are now delivered this way while more than 40% of deliveries in China are via caesarean section.

Caesarean sections, involving the delivery of single or multiple babies via an incision in the mother's abdomen and uterus, have been performed since Roman times. As the safety of the procedure has improved, the number of caesarean sections has increased significantly.

Says Penningtons partner, Alison Appelboam-Meadows: "As with all surgery, the risks must be weighed up against the benefits of the surgery. A caesarean section is invasive abdominal surgery with associated risks to the mother and, to a lesser extent, to the child. The risks to the mother include infection, severe bleeding, stroke and the risk of uterine rupture in future pregnancies. It is not unheard of for the baby to suffer injuries from the surgery and other risks can include lung problems and prematurity if the baby is delivered early.

"While caesarean sections are usually performed because of perceived risks to the health of the unborn child, there is increasing incidence of caesareans being carried out when there is no true medical need for such invasive surgery".

Can women demand a caesarean section?

Historically, women have not been able to insist on caesarean sections being carried out on the NHS in the UK. The guidelines published by the National Institute for Health and Clinical Excellence (NICE) in April 2004 made it clear that maternal request was not, on its own, an indication for a caesarean section to be carried out and clinicians had the right to decline such requests if there were no reasons to advocate this mode of delivery.

The position was altered slightly, however, by NICE's guidelines on caesarean sections, published in November 2011, which received much press coverage because of the purported new right for women to have caesarean sections on the NHS.

In fact, the guidelines make it clear that, as before, if a woman specifically requests a caesarean section, the clinician should explore the reasons for this and discuss with her the risks and benefits of caesarean section compared with vaginal delivery. (If a woman has a fear of childbirth, she should be referred for support but, if a vaginal birth is still not an acceptable option, her request for a caesarean section should be supported.)

Balancing risks versus benefits

Penningtons has acted for a number of women who have sustained injuries as a result of undergoing caesarean sections. In one case, an emergency caesarean was correctly carried out because of the failure to progress in labour but the mother sustained a tear to her uterus which was not properly explored and sutured before closure. This resulted in ongoing blood loss and, ultimately, multiple laparotomies and a hysterectomy.

In another case, where the mother underwent a planned caesarean for a breech presentation, her bowel was perforated – another recognised risk - but there was a failure to review and assess her properly post-operatively. This resulted in a delayed emergency laparotomy, severe peritonitis and a very difficult recovery and prolonged hospital stay.

Despite these risks, there are circumstances where the treating clinicians would be failing in their duty of care if they did not advocate delivery by caesarean section. In the UK, a significant number of the claims handled by the National Health Service Litigation Authority, (NHSLA), on behalf of the NHS, arise because babies have suffered significant brain injuries as a result of the delay in their deliveries. In such cases, it is often argued that injury would have been avoided if the baby had been delivered by caesarean section in good time.

Fear of litigation has often been proposed as one reason why the number of caesarean sections has increased. However, Alison Appelboam-Meadows continues to see a significant number of cases where warning signs have been missed and harm has been caused because deliveries have not been expedited by caesarean section.

Says Alison: "We acted on behalf of a little boy who suffered severe athetoid cerebral palsy as a result of a lack of oxygen and circulatory insufficiency at the time of his birth. All of his injuries would have been avoided if his mother's treating clinicians had heeded the fetal distress evident on the CTG monitoring and delivered him by caesarean section just 10 minutes before he was actually delivered. That little boy now requires round-the-clock care for the rest of his life because of his severe physical disabilities".

In summary, the decision to proceed with a caesarean section should not to be taken lightly. The risks and benefits of the procedure, both to the mother and the child, should be carefully considered taking into account the very specific facts of the pregnancy and delivery and appreciating that emergency situations may arise, with decisions as to the mode of delivery being reviewed at this stage.

International Caesarean Awareness Month is promoted by the International Cesarean Awareness Network (ICAN), a non-profit advocacy and support group based in the USA. Its mission is to improve maternal and child health by preventing unnecessary caesareans through education, provide support for caesarean recovery, and promote vaginal birth after caesarean (VBAC).